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Home , Bile acid malabsorption

Diarrhoea

What is diarrhoea? What actually happens People say they have diarrhoea The physiology of diarrhoea when their bowel movements are Diarrhoea occurs as a result of a disruption more frequent or looser, sloppier or in the balance of absorption and secretion of fluid in the gut. We tend to take in about 1 to 2 more watery than usual. There is a litres of fluid a day as part of our diet. To this is considerable range in frequency and added another 8 litres of digestive juices, from consistency of bowel movements. saliva, gastric juice, pancreatic secretions, bile and the secretions of the . But, for people on a western diet, Most of this fluid is absorbed along with diarrhoea usually means passing more nutrients in the small intestine leaving about than three soft or sloppy stools per 1 litre of a thick yellow slurry containing day (type 4-7 on the Bristol Stool undigested remains of food to enter the colon each day. The colon salvages nutrients from this Chart, see page 2). slurry, converting unabsorbed sugars, starches When diarrhoea is a feature of IBS, it is and proteins into short-chain fatty acids which associated with crampy and/or can be absorbed through the colon wall along and may alternate with . with salt and water. This leaves a solid plug of Severe diarrhoea can result in urgency or even about 150g of bacteria and indigestible fibre, faecal incontinence. which is evacuated. We all have diarrhoea from time to time. It is Diarrhoea occurs when this process gets out part of life and can occur if we are anxious or of balance. This can be caused by excessive upset, or if we have eaten or drunk anything secretion into the gut, impaired absorption, that has upset us. It can often occur on holiday accelerated propulsion, and a failure of colonic – commonly known as travelers’ diarrhoea, salvage. All these processes can occur together. when it may be the result of or For example, during food poisoning, bacteria food poisoning. or viruses stimulate excessive secretion of For most people, diarrhoea is a short-lived fluid into the small intestine along with strong inconvenience. But, for people with diarrhoea propulsive contractions. This allows insufficient predominant IBS (known as IBS-D), diarrhoea time for nutrients to be completely absorbed occurs frequently, often without any warning and overwhelms the capacity for colonic and may continue for years and cause people salvage. In this way the gut clears the infection to feel very anxious and embarrassed. by flushing it out. pain and diarrhoea after an attack of gastroenteritis. There is no sign of infection but the bowel is mildly inflamed and more sensitive to stress and food. Post infectious IBS is more likely to occur if a person is anxious or depressed at the time of the gastroenteritis. • Post-traumatic IBS. Many cases of IBS are instigated by a particularly upsetting life event or a period of life stress with which has not been properly dealt. Anything that reminds you of what happened can rekindle the symptoms that were going on at the time. • Small Intestinal Bacterial Overgrowth (SIBO). Administration of acid blockers to treat symptoms of peptic ulceration or gastro-oesophageal reflux disease, (GERD), may lead to colonization of the small intestine by bacteria. These may degrade fat and Medical causes of ferment protein and carbohydrate, reducing their absorption and result in symptoms of diarrhoea diarrhoea and IBS. Slow small bowel transit • Gastroenteritis. Bacterial and viral infections and ingestion of probiotics might also of the bowel tend to cause an attack of predispose to bacterial overgrowth. SIBO is vomiting and diarrhoea and cramping thought to be responsible for about 30% abdominal pain that rarely lasts longer than of cases of IBS. This is almost certainly an three days. In some people, however, the overestimate due to misinterpretation of symptoms can last much longer even though breath tests. any evidence of infection has disappeared. This • Food intolerance. Most people with IBS is known as post infectious diarrhoea. Some report some intolerance to food. Food parasitic infections such as amoebiasis and intolerance is not the same as allergy. Any giardiasis can cause diarrhoea that may last food can be taken in small amounts, but several months. people with sensitive guts tolerate less • Inflammatory Bowel Disease.Ulcerative than otherwise healthy people. It depends , Crohn’s Disease, on portion size. The following are a list of and cause inflammation which foods which may cause diarrhoea if taken in irritates the lining of the bowel causing amounts that exceed personal tolerance. secretion and propulsion, often associated • beans and lentils with blood and mucus in the stool. • onions • Post-infectious IBS. About 10% of people • cauliflower develop long lasting symptoms of abdominal • beetroot • stone fruits thought of in somebody over 50 who has • apples and pears experienced a recent alteration in bowel habit • hot spices, such as chilli, pepper and for no obvious reason, especially if they have ginger lost weight and been passing blood in their motions. • high fibre foods • alcohol If blood tests for are positive, • coffee. it is usually necessary to obtain a biopsy of the lining of the small intestine via a • . After weaning, about gastroscope and perhaps also to carry out tests 20% of people living in the UK lose the of pancreatic function. Coeliac Disease and lactase enzyme that digests milk sugar. This can then be treated with is not necessarily a problem because the diets. colon normally has the capacity to salvage • Cancer of the bowel. If you are over the age lactose by fermentation. However, if you of 50 and experience any persistent change in have a combination of lactase deficiency and bowel habit coming on for no obvious reason, a sensitive bowel, drinking more than half a it is important that tests are carried out to pint of milk is likely to cause diarrhoea. exclude cancer. What can your • Coeliac Disease. Coeliac Disease occurs in 4% of people diagnosed with IBS. It is caused doctor do? by an allergy to gluten, which destroys the You should see your doctor if your diarrhoea cells lining the small intestine and results is has been going on for more than a few weeks impaired absorption of nutrients and very for no obvious reason. This is especially loose motions, and in severe cases, weight important if you have lost weight, felt generally loss, anaemia and fragile bones. unwell or have been losing blood in your • Chronic . Lack of pancreatic motions. enzymes impairs , especially of fat, Doctors will usually take a detailed history which is converted to irritant hydroxy fatty of your illness, particularly noting any links acids in the colon. between the pattern of your symptoms and • Some hormone conditions. These include your diet, stressful life events, trips abroad and overactive thyroid, hyperparathyroidism and changes in medication. They may examine you diabetes. and carry out specific tests of your blood to screen for Coeliac Disease and inflammatory • Surgery. Removal of segments of small bowel disease. They may also ask you to intestine or colon, (removal collect a sample of stool, which may be useful of the gall bladder), and gastric by-pass may to identify the presence of parasites such all result in diarrhoea. as amoeba or giardia, as well as to test for • Some drugs. Many medications cause inflammation in the bowel. If the latter is diarrhoea. These include antibiotics, antacids positive or borderline, your doctor may refer containing magnesium, some antidepressants you to hospital for a colonoscopy or barium and drugs that lower blood pressure or reduce enema to look for colonic inflammation or cholesterol levels. Read the product leaflets cancer. Cancer of the bowel must always be to find out. Some herbal preparations for the gut may contain senna or cascara, which are strong laxatives. (BAM) • Antibiotic associated diarrhoea. Courses of Normally secreted into the small intestine in broad spectrum antibiotics, used to treat severe response to the arrival of food, bile acids assist infections elsewhere, can deplete the normal the absorption of fat and are then reabsorbed colonic bacterial flora (colonic microbiome), from the last foot of small intestine, (the terminal impairing bacterial salvage by fermentation ), to return to the . If propulsion of unabsorbed carbohydrate and protein. In through the small intestine is particularly rapid, some cases, this bacterial depletion can lead it may prevent the reabsorption of bile acids, so to an overgrowth of harmful species such as more of them enter the colon where they are Clostridium difficile, which can cause a serious converted by bacteria to compounds that are colonic inflammation. intensely irritant. Studies have shown that about 30% of people with IBS Diarrhoea have impaired • Food allergy. Food allergy is thought to affect absorption of bile acids. There is some evidence no more than 2% of adults and about 6% of that bile acid malabsorption (BAM) is also caused children. Common allergens include peanuts, by a genetic defect in the protein responsible for strawberries and shellfish. Blood tests for transporting bile acids. antibodies for common foods, (Yorktest), suggest that the gut wall is leaky to food proteins and therefore has the capability to What you can do develop an allergic reaction to them. However, If all the tests have failed to reveal an obvious the evidence is controversial and such tests are cause for your diarrhoea, then you may be told not available on the NHS. that you have . This does not mean you have to suffer in silence. There is a Diarrhoea predominant lot you can do yourself. Look at our website for IBS advice. In diarrhoea associated with IBS, the bowel is Coping with food often excessively sensitive to stress and the presence of food, stimulating secretion and intolerance propagating contractions which propel food The gut in IBS, especially in people with through the intestine too rapidly to be completely diarrhoea, is particularly sensitive and this can absorbed. This may overwhelm the salvage vary according to how tense you feel. Foods that capacity of the colon, resulting in diarrhoea. In normally stimulate the intestine are particularly particular, unabsorbed fats may be converted in likely to generate diarrhoea in a sensitive gut. the colon to hydroxyl-fatty acids which irritate These include onions and pulses, some fruits the colon. Research has indicated that a specific and fruit juices, hot spices, milk, (in people who transmitter substance, called serotonin, released are lactose deficient), wheat (in some people), from cells lining the intestine, plays a key role in and alcoholic drinks, especially beer and red mediating this extreme sensitivity. wine. Food intolerance is not like food allergy. Most people can tolerate some of the above foods. It depends on portion size. Moreover, food intolerance can come and go according to how you feel. So a pragmatic solution might be to Medications reduce the intake of those foods that are likely Most of the drugs that are used to treat to cause problems. Then, after your symptoms diarrhoea can be purchased over the counter have abated, you can try to increase the amount from your local pharmacist. again. If you get into difficulties, then ask for a Loperamide Hydrochloride (Imodium), referral to a specialist FODMAP trained Dietitian. acts on the gut to suppress secretion and Don’t let food intolerance rule your life. colonic propulsion. It is the most powerful Dealing with stress antidiarrhoeal drug available over the counter. Codeine Phosphate acts in a similar manner We all know that stress can affect the bowels. but also behaves as a mild tranquilliser, but may Situations that irritate and frighten you or just cause drowsiness. feeling overwhelmed by work and responsibility may cause diarrhoea. If those feelings are Cholestyramine (Questran) is a resin that acts suppressed and you just soldier on, then the within the gut to mop up bile acids. It needs diarrhoea may persist. Ask yourself whether to be taken about half an hour before meals so anything might be keeping the diarrhoea going it is around before the bile acids are secreted. and try to get your life in balance and deal with You will need to measure and balance the dose whatever is happening, or has happened. The with the size of the meal and the response of trigger may be something seemingly innocuous your symptoms in order to find the regimen that reminds you of a much more serious that is right for you. Questran is not absorbed event in the past. If you think that the tension into the body and can be taken together with induced by unresolved life situations might other anti-diarrhoeal drugs. It can only be be responsible for your symptoms, consider obtained on prescription from your doctor. Bile talking to a friend or a professional counsellor acid sequestrants are also available in tablet or therapist. Alternatively, try to find space in form, but are less easy to balance. They include your life by doing something that relaxes you (Welchol). and gives you the peace of mind to get things If your diarrhoea is very severe and you are into perspective. You might like to consider losing a lot of fluid, your doctor may advise complementary therapies; any of them can you to take oral rehydration solutions such as help to give you confidence and support. Touch Dioralyte. These will not necessarily improve the therapies such as reflexology, acupuncture, diarrhoea but they will prevent you from getting Reiki therapy and therapeutic massage, can dangerously dehydrated. be particularly effective. Bowel directed hypnotherapy is particularly effective in slowing the bowel down in patients with functional diarrhoea. Diarrhoea

Further Reading About this factsheet Hammer, HF. Chronic , An Issue of This Factsheet was written by Professor Clinics, 1st Edition. Elsevier, Nick Read, M.A., M.D, F.R.C.P Medical 2012. Adviser to The IBS Network, July 2016. International Federation for Functional Gastrointestinal Disorders. Managing It is published by The IBS Network, the Diarrhoea. http://iffgd.org/lower-gi-disorders/ national charity supporting people living diarrhea/managing-diarrhea.html with Irritable Bowel Syndrome, as a Ransley JK and Read NW. Cooking for The service to those with IBS, and healthcare Sensitive Gut, London, Pavilion Books, 2016. professionals.

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